Intracerebral endotheliitis and microbleeds are neuropathological features of COVID-19

Coronavirus disease 19 (COVID‐19) is a rapidly evolving pandemic caused by the coronavirus Sars‐CoV‐2. Clinically manifest central nervous system symptoms have been described in COVID‐19 patients and could be the consequence of commonly associated vascular pathology, but the detailed neuropathological sequelae remain largely unknown. A total of six cases, all positive for Sars‐CoV‐2, showed evidence of cerebral petechial hemorrhages and microthrombi at autopsy. Two out of six patients showed an elevated risk for disseminated intravascular coagulopathy according to current criteria and were excluded from further analysis. In the remaining four patients, the hemorrhages were most prominent at the grey and white matter junction of the neocortex, but were also found in the brainstem, deep grey matter structures and cerebellum. Two patients showed vascular intramural inflammatory infiltrates, consistent with Sars‐CoV‐2‐associated endotheliitis, which was associated by elevated levels of the Sars‐CoV‐2 receptor ACE2 in the brain vasculature. Distribution and morphology of patchy brain microbleeds was clearly distinct from hypertension‐related hemorrhage, critical illness‐associated microbleeds and cerebral amyloid angiopathy, which was ruled out by immunohistochemistry. Cerebral microhemorrhages in COVID‐19 patients could be a consequence of Sars‐ CoV‐2‐induced endotheliitis and more general vasculopathic changes and may correlate with an increased risk of vascular encephalopathy.

Transcutaneous vagal nerve stimulation blocks stress-induced activation of Interleukin-6 and interferon-γ in posttraumatic stress disorder: A double-blind, randomized, sham-controlled trial

Posttraumatic stress disorder (PTSD) is a highly disabling condition associated with alterations in multiple neurobiological systems, including increases in inflammatory function. Vagus nerve stimulation (VNS) decreases inflammation, however few studies have examined the effects of non-invasive VNS on physiology in human subjects, and no studies in patients with PTSD. The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on inflammatory responses to stress. Thirty subjects with a history of exposure to traumatic stress with (N ​= ​10) and without (N ​= ​20) PTSD underwent exposure to stressful tasks immediately followed by active or sham tcVNS and measurement of multiple biomarkers of inflammation (interleukin-(IL)-6, IL-2, IL-1β, Tumor Necrosis Factor alpha (TNFα) and Interferon gamma (IFNγ) over multiple time points. Stressful tasks included exposure to personalized scripts of traumatic events on day 1, and public speech and mental arithmetic (Mental Stress) tasks on days 2 and 3. Traumatic scripts were associated with a pattern of subjective anger measured with Visual Analogue Scales and increased IL-6 and IFNγ in PTSD patients that was blocked by tcVNS (p ​< ​.05). Traumatic stress had minimal effects on these biomarkers in non-PTSD subjects and there was no difference between tcVNS or sham. No significant differences were seen between groups in IL-2, IL-1β, or TNFα. These results demonstrate that tcVNS blocks behavioral and inflammatory responses to stress reminders in PTSD.

The Prevalence and Stability of Sleep-Wake Disturbance and Fatigue throughout the First Year after Mild Traumatic Brain Injury

In this prospective, longitudinal study, we aimed to determine the prevalence and stability of sleep-wake disturbance (SWD) and fatigue in a large representative sample of patients (Trondheim mild traumatic brain injury [mTBI] follow-up study). We included 378 patients with mTBI (age 16-60), 82 matched trauma controls with orthopedic injuries, and 83 matched community controls. Increased sleep need, poor sleep quality, excessive daytime sleepiness, and fatigue were assessed at 2 weeks, 3 months, and 12 months after injury. Mixed logistic regression models were used to evaluate clinically relevant group differences longitudinally. Prevalence of increased sleep need, poor sleep quality, and fatigue was significantly higher in patients with mTBI than in both trauma controls and community controls at all time points. More patients with mTBI reported problems with excessive daytime sleepiness compared to trauma controls, but not community controls, at all time points. Patients with complicated mTBI (intracranial findings on computed tomography or magnetic resonance imaging) had more fatigue problems compared to those with uncomplicated mTBI, at all three time points. In patients with mTBI who experienced SWDs and fatigue 2 weeks after injury, around half still had problems at 3 months and approximately one third at 12 months. Interestingly, we observed limited overlap between the different symptom measures; a large number of patients reported one specific problem with SWD or fatigue rather than several problems. In conclusion, our results provide strong evidence that mTBI contributes significantly to the development and maintenance of SWDs and fatigue.

What Are the Interobserver and Intraobserver Variability of Gap and Stepoff Measurements in Acetabular Fractures?

BACKGROUND

Gap and stepoff values in the treatment of acetabular fractures are correlated with clinical outcomes. However, the interobserver and intraobserver variability of gap and stepoff measurements for all imaging modalities in the preoperative, intraoperative, and postoperative phase of treatment is unknown. Recently, a standardized CT-based measurement method was introduced, which provided the opportunity to assess the level of variability.

QUESTIONS/PURPOSES

(1) In patients with acetabular fractures, what is the interobserver variability in the measurement of the fracture gaps and articular stepoffs determined by each observer to be the maximum one in the weightbearing dome, as measured on pre- and postoperative pelvic radiographs, intraoperative fluoroscopy, and pre- and postoperative CT scans? (2) What is the intraobserver variability in these measurements?

METHODS

Sixty patients with a complete subset of pre-, intra- and postoperative high-quality images (CT slices of < 2 mm), representing a variety of fracture types with small and large gaps and/or stepoffs, were included. A total of 196 patients with nonoperative treatment (n = 117), inadequate available imaging (n = 60), skeletal immaturity (n = 16), bilateral fractures (n = 2) or a primary THA (n = 1) were excluded. The maximum gap and stepoff values in the weightbearing dome were digitally measured on pelvic radiographs and CT images by five independent observers. Observers were free to decide which gap and/or stepoff they considered the maximum and then measure these before and after surgery. The observers were two trauma surgeons with more than 5 years of experience in pelvic surgery, two trauma surgeons with less than 5 years of experience in pelvic surgery, and one surgical resident. Additionally, the final intraoperative fluoroscopy images were assessed for the presence of a gap or stepoff in the weightbearing dome. All observers used the same standardized measurement technique and each observer measured the first five patients together with the responsible researcher. For 10 randomly selected patients, all measurements were repeated by all observers, at least 2 weeks after the initial measurements. The intraclass correlation coefficient (ICC) for pelvic radiographs and CT images and the kappa value for intraoperative fluoroscopy measurements were calculated to determine the inter- and intraobserver variability. Interobserver variability was defined as the difference in the measurements between observers. Intraobserver variability was defined as the difference in repeated measurements by the same observer.

RESULTS

Preoperatively, the interobserver ICC was 0.4 (gap and stepoff) on radiographs and 0.4 (gap) and 0.3 (stepoff) on CT images. The observers agreed on the indication for surgery in 40% (gap) and 30% (stepoff) on pelvic radiographs. For CT scans the observers agreed in 95% (gap) and 70% (stepoff) of images. Postoperatively, the interobserver ICC was 0.4 (gap) and 0.2 (stepoff) on radiographs. The observers agreed on whether the reduction was acceptable or not in 60% (gap) and 40% (stepoff). On CT images the ICC was 0.3 (gap) and 0.4 (stepoff). The observers agreed on whether the reduction was acceptable in 35% (gap) and 38% (stepoff). The preoperative intraobserver ICC was 0.6 (gap and stepoff) on pelvic radiographs and 0.4 (gap) and 0.6 (stepoff) for CT scans. Postoperatively, the intraobserver ICC was 0.7 (gap) and 0.1 (stepoff) on pelvic radiographs. On CT the intraobserver ICC was 0.5 (gap) and 0.3 (stepoff). There was no agreement between the observers on the presence of a gap or stepoff on intraoperative fluoroscopy images (kappa -0.1 to 0.2).

CONCLUSIONS

We found an insufficient interobserver and intraobserver agreement on measuring gaps and stepoffs for supporting clinical decisions in acetabular fracture surgery. If observers cannot agree on the size of the gap and stepoff, it will be challenging to decide when to perform surgery and study the results of acetabular fracture surgery.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Question

Is low-dose whole-body computed tomography with statistical image reconstruction associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma?

Findings

In this quasi-experimental cohort study of 971 patients with suspected blunt multiple trauma, participants in the standard-dose and low-dose whole-body computed tomography groups had the same risk of missed injury diagnoses. Low-dose scanning markedly reduced exposure to radiation, improved the contrast-to-noise ratio, and showed similar diagnostic accuracy among the investigated anatomical areas and organs when compared with standard-dose scanning.

Meaning

These findings suggest that low-dose whole-body computed tomography may safely replace standard-dose scanning in the primary diagnostic workup of blunt multiple trauma.

Importance

Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure.

Objective

To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure.

Design, Setting, and Participants

This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019.

Interventions

Standard- or low-dose WBCT.

Main Outcomes and Measures

The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy.

Results

Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001).

Conclusions and Relevance

Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

Is the Regular Intake of Anticoagulative Agents an Independent Risk Factor for the Severity of Traumatic Brain Injuries in Geriatric Patients? A Retrospective Analysis of 10,559 Patients from the TraumaRegister DGU®

The purpose of this study was to assess anticoagulant medication as an independent factor influencing the occurrence of a severe traumatic brain injury in geriatric patients. Data were collected from the TraumaRegister DGU^® between January 2015 and December 2018. We included patients with an age of ≥65 years with a blunt TBI; an AISHead ≥2 but no other relevant injuries. Patients were divided into five subgroups: no anticoagulant medication, anti-platelet drugs, vitamin K antagonists, direct-oral-anticoagulants, and heparinoids. Separation between moderate TBI (AISHead 2–3) and severe TBI (AISHead ≥ 4) and multivariable regression analysis were performed. The average age of 10,559 included patients was 78.8 years with a mean ISS of 16.8 points and a mortality of 22.9%. The most common cause of injury was a low fall of <3 m with 72.8%. With increasing age, the number of patients without any anticoagulant therapy decreased from 65.9% to 29.9%. The intake of coagulation medication increased mortality significantly. Severe TBI was observed in 51% of patients without medication and ranged from 61 to 67% with anticoagulant drugs. After adjusting for confounding variables, the intake of VKA or DOACs was significantly associated with an increased risk of severe TBI. The use of anticoagulant medication is an independent factor and is associated with an increased severity of TBI depending on the type of medication used.

Manipulation of Autophagy and Apoptosis Facilitates Intracellular Survival of Staphylococcus aureus in Human Neutrophils

Polymorphonuclear neutrophils (PMN) are critical for first line innate immune defence against Staphylococcus aureus. Mature circulating PMN maintain a short half-life ending in constitutive apoptotic cell death. This makes them unlikely candidates as a bacterial intracellular niche. However, there is significant evidence to suggest that S. aureus can survive intracellularly within PMN and this contributes to persistence and dissemination during infection. The precise mechanism by which S. aureus parasitizes these cells remains to be established. Herein we propose a novel mechanism by which S. aureus subverts both autophagy and apoptosis in PMN in order to maintain an intracellular survival niche during infection. Intracellular survival of S. aureus within primary human PMN was associated with an accumulation of the autophagic flux markers LC3-II and p62, while inhibition of the autophagy pathway led to a significant reduction in intracellular survival of bacteria. This intracellular survival of S. aureus was coupled with a delay in neutrophil apoptosis as well as increased expression of several anti-apoptotic factors. Importantly, blocking autophagy in infected PMN partially restored levels of apoptosis to that of uninfected PMN, suggesting a connection between the autophagic and apoptotic pathways during intracellular survival. These results provide a novel mechanism for S. aureus intracellular survival and suggest that S. aureus may be subverting crosstalk between the autophagic and apoptosis pathways in order to maintain an intracellular niche within human PMN.

Oral and maxillofacial surgeons' assessment of the role of Pernkopf's atlas in surgical practice

BACKGROUND

The use of the Pernkopf atlas of human anatomy in surgery presents ethical challenges due to the author's association with the Nazi regime and the potential depiction of victims of this regime. The atlas was of particular utility to two surgical specialties: nerve surgeons and oral and maxillofacial surgeons. The representation of peripheral nerves and complex head and neck anatomy is probably unequaled in any other atlas of anatomy. While the ethical implications of the use of Pernkopf's atlas among nerve surgeons have been previously assessed, this study focuses on the volume dedicated to detailed images of head and neck dissections, and the ethical implications of using this atlas by oral and maxillofacial surgeons.

OBJECTIVE

To (1) assess the role of the Pernkopf atlas in oral and maxillofacial surgeons' current practice and (2) determine whether a proposal of four conditions would provide ethical guidance for use in surgery and education.

METHODS

Members of three American oral and maxillofacial surgical societies (ACOMS, ASTMJS, AAOMS) were surveyed and 181 responses collected. The survey introduced the historical origin of the Pernkopf atlas, and respondents were asked whether they would use the atlas under specific conditions that could be a recommendation for its ethical handling. An anatomical plate comparison between Netter's and Pernkopf's atlases was performed to compare accuracy and surgical utility.

RESULTS

Forty-nine percent of respondents were aware of the Pernkopf atlas, and 9% of respondents were currently using it. Amongst those aware of the historical facts, 42% were comfortable using the atlas, 33% uncomfortable, and 25% undecided. The four conditions involving disclosure, bioethical and religious considerations, and remembrance led to 75% of those "uncomfortable" and "undecided" becoming "comfortable" with use.

CONCLUSIONS

Amid recent developments and controversy regarding the Pernkopf atlas, a proposal detailing conditions for an ethical approach may provide guidance in surgical planning and education. Furthermore, this approach has implications for the future preparation and publication of anatomical atlases and their use.

Is There Any Difference in the Outcome of Geriatric and Non-Geriatric Severely Injured Patients?-A Seven-Year, Retrospective, Observational Cohort Study with Matched-Pair Analysis

Geriatric trauma is expected to increase due to the lifestyle and activity of the aging population and will be among the major future challenges in health care. Therefore, the aim of this study was to investigate differences between polytraumatized geriatric and non-geriatric patients regarding mortality, length-of-stay and complications with a matched pair analysis. We included patients older than 17 years with an Injury Severity Score (ISS) of 16 or more admitted to our level 1 trauma center between January 2008 and December 2015. The cohort was stratified into two groups (age < 70 and ≥ 70 years). One-to-one matching was performed based on gender, ISS, mechanism of injury (penetrating/blunt), Glasgow coma scale (GCS), base excess, and the presence of coagulopathy (international normalized ratio (INR) ≥ 1.4). Outcome was compared using the paired t-test and McNemar-test. A total of 1457 patients were identified. There were 1022 male (70%) and 435 female patients. Three hundred and sixty-four patients (24%) were older than 70 years. Matching resulted in 57 pairs. Mortality as well as length-of-stay were comparable between geriatric and non-geriatric polytraumatized patients. Complication rate (34% vs. 56%, p = 0.031) was significantly higher in geriatric patients. This indicates the possibility of similar outcomes in geriatric polytraumatized patients receiving optimal care.

Classification of tibial plateau fractures using 3DCT with and without subtraction of unfractured bones

BACKGROUND

The addition of 3D CT scans for observers evaluating tibial plateau fractures decreases agreement and diagnostic accuracy, possibly due to obstruction of the view by unfractured bones (i.e., patella, fibula, and femur) in 3D reconstructions.

QUESTIONS/PURPOSES

This study compared (1) the interobserver agreement between (subgroups of) observers classifying 3DCT reconstructions of tibial plateau fractures according to Schatzker, Luo, and AO/OTA, (2) recognition of different fracture characteristics, and (3) the level of confidence on a scale from 0 to 10 with and without subtraction of the unfractured bones.

METHODS

We selected twenty consecutive 3DCT reconstructions of tibial plateau fractures treated in a level I trauma center between 2013 and 2014. Members of the Science of Variation Group were randomized (1:1) to evaluate reconstructions with or without subtraction of the unfractured bone. Forty-nine surgeons completed the survey. The interobserver agreement was determined using Fleiss' kappa, and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and confidence intervals.

RESULTS

Overall, subtraction of unfractured bones did not affect interobserver agreement in Schatzker, Luo, and AO/OTA classification systems, agreement on the presence of fracture characteristics, and level of confidence. In subgroup analysis, non-trauma surgeons had significantly higher agreement in the three classification systems with subtraction. For fracture characteristics, some subgroups had higher agreement while others had lower agreement with subtraction.

DISCUSSION

The finding that agreement on classification of tibial plateau fractures is limited on 3DCT scan and is not improved by subtraction of unfractured bones suggests that disagreement may be based on variations in understanding and bias. Reliability of these classification systems might benefit from a focus on accounting for these pre-existing conceptualizations rather than further emphasis on imaging detail.

LEVEL OF EVIDENCE

Diagnostic, level 1.

Peripheral inflammation is strongly linked to elevated zero maze behavior in repeated social defeat stress

Post-traumatic stress disorder (PTSD) is a psychiatric illness that results in an increased risk for a variety of inflammatory diseases. The exact etiology of this increased risk is unknown, and thus several animal models have been developed to investigate the neuroimmune interactions of PTSD. Repeated social defeat stress (RSDS) is an established preclinical model of psychological trauma that recapitulates certain behavioral and inflammatory aspects of human PTSD. Furthermore, RSDS has been utilized to subgroup animals into susceptible and resilient populations based on one specific behavioral phenotype (i.e., social interaction). Herein, we conducted an extensive investigation of circulating inflammatory proteins after RSDS and found significant elevations in various cytokines and chemokines after exposure to RSDS. When categorizing animals into either susceptible or resilient populations based on social interaction, we found no inflammatory or other behavioral differences between these subgroups. Furthermore, correlative analyses found no significant correlation between social interaction parameters and inflammation. In contrast, parameters from the elevated zero maze (EZM) demonstrated significant associations and clustering to five circulating cytokines. When animals were subdivided into susceptible and resilient populations solely based upon combined EZM performance, significant inflammatory differences were evident between these groups. Strikingly, these circulating inflammatory proteins displayed a stronger predictive ability of EZM performance compared to social interaction test performance. These findings provide new insights into inflammatory markers associated with RSDS, and the utility of EZM to effectively group RSDS-exposed mice into populations with differential levels of peripheral inflammation.

The interaction of the circadian and immune system: Desynchrony as a pathological outcome to traumatic brain injury

Traumatic brain injury (TBI) is a complex and costly worldwide phenomenon that can lead to many negative health outcomes including disrupted circadian function. There is a bidirectional relationship between the immune system and the circadian system, with mammalian coordination of physiological activities being controlled by the primary circadian pacemaker in the suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN receives light information from the external environment and in turn synchronizes rhythms throughout the brain and body. The SCN is capable of endogenous self-sustained oscillatory activity through an intricate clock gene negative feedback loop. Following TBI, the response of the immune system can become prolonged and pathophysiological. This detrimental response not only occurs in the brain, but also within the periphery, where a leaky blood brain barrier can permit further infiltration of immune and inflammatory factors. The prolonged and pathological immune response that follows TBI can have deleterious effects on clock gene cycling and circadian function not only in the SCN, but also in other rhythmic areas throughout the body. This could bring about a state of circadian desynchrony where different rhythmic structures are no longer working together to promote optimal physiological function. There are many parallels between the negative symptomology associated with circadian desynchrony and TBI. This review discusses the significant contributions of an immune-disrupted circadian system on the negative symptomology following TBI. The implications of TBI symptomology as a disorder of circadian desynchrony are discussed.

Preventable Trauma Deaths and Corrective Actions to Prevent Them: A 10-Year Comparative Study at the Komfo Anokye Teaching Hospital, Kumasi, Ghana

OBJECTIVE

To determine the rate of preventable trauma deaths in an African hospital, identify the potential effect of improvements in trauma care over the past decade and identify deficiencies in care that still need to be addressed.

METHODS

A multidisciplinary panel assessed pre-hospital, hospital, and postmortem data on 89 consecutive in-hospital trauma deaths over 5 months in 2017 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For definitely and potentially preventable deaths, the panel identified deficiencies in care.

RESULTS

Thirteen percent (13%) of trauma deaths were definitely preventable, 47% potentially preventable, and 39% non-preventable. In comparison with a panel review in 2007, there was no change in total preventable deaths, but there had been a modest decrease in definitely preventable deaths (25% in 2007 to 13% in 2017, p = 0.07) There was a notable change in the pattern of deficiency (p = 0.001) with decreases in pre-hospital delay (19% of all trauma deaths in 2007 to 3% in 2017) and inadequate resuscitation (17 to 8%), but an increase in delay in treatment at the hospital (23 to 40%).

CONCLUSIONS

Over the past decade, there have been improvements in pre-hospital transport and in-hospital resuscitation. However, the preventable death rate remains unacceptably high and there are still deficiencies to address. This study also demonstrates that preventable death panel reviews are a feasible method of trauma quality improvement in the low- and middle-income country setting.

Low glucocorticoids in stress-related disorders: the role of inflammation

There is evidence that plasma cortisol concentration can be either increased or decreased in patients with depression and related anxiety and stress-related disorders; the exact pathophysiological mechanisms of this state are not almost clear. Several distinct theories were proposed and mechanisms, which could lead to decreased glucocorticoid signaling and/or levels, were described. However, there is a possible drawback in almost all the theories proposed: insufficient attention to the inflammatory process, which is undoubtedly present in several stress-related disorders, including post-traumatic stress disorder (PTSD). Previous studies only briefly mentioned the presence of an inflammatory reaction's signs in PTSD, without giving it due importance, although recognizing that it can affect the course of the disease. With that, the state of biochemical changes, characterized by the low glucocorticoids, glucocorticoid receptor's resistance and the signs of the persistent inflammation (with the high levels of circulating cytokines) might be observed not only in PTSD but in coronary heart diseases and systemic chronic inflammatory diseases (rheumatoid arthritis) as well. That is why the present review aims to depict the pathophysiological mechanisms, which lead to a decrease in glucocorticoids in PTSD due to the action of inflammatory stimuli. We described changes in the glucocorticoid system and inflammatory reaction as parts of an integral system, where glucocorticoids and the glucocorticoid receptor reside at the apex of a regulatory network that blocks several inflammatory pathways, while decreased glucocorticoid signaling and/or level leads to unchecked inflammatory reactions to promote pathologies such as PTSD. LAY SUMMARY This review emphasizes the importance of inflammatory reaction in the development of puzzling conditions sometimes observed in severe diseases including post-traumatic stress disorder - the decreased levels of glucocorticoids in the blood. Following the classical concepts, one would expect an increase in glucocorticoid hormones, since they are part of the feedback mechanism in the immune system, which reduces stress and inflammation. However, low levels of glucocorticoid hormones are also observed. Thus, this review describes potential mechanisms, which can lead to the development of such a state.

Surgical Supply Cost Awareness Is Associated With Lower Costs: A Single-Center Experience

Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.

Evaluation of Protein Carbonyl Content in Healthy and Sick Hospitalized Horses

Literature on the protein carbonyl content (PCC) evaluation in horses is scarce, thus the aims were to evaluate the PCC in healthy and SIRS (Systemic Inflammatory Response Syndrome) horses and to investigate the performances of PCC in terms of sensitivity, specificity, and likelihood ratio in identifying SIRS positive and negative horses. A total of 72 adult horses were included. All the horses underwent to a complete physical examination, blood analysis, and were evaluated for the SIRS status. Blood samples were collected once in healthy horses and at admission time, then 24, 48, 72, and 96 h after admission in sick animals. PCC was evaluated using a method previously described. Data were statistically analyzed to verify differences in PCC between healthy vs. SIRS positive or SIRS negative horses at all sampling time. The receiver operating characteristic (ROC) curve was performed to verify sensitivity and specificity of PCC in the diagnosis of SIRS-positive and SIRS negative horses. The healthy horses were standardbred mares with a median age of 8.5 years. The sick horses were 31/54 females, 16/54 geldings, and 7/54 stallions of different breeds and with a median age of 12 years old. Eight out of 54 sick horses were SIRS negative, while 46/54 were SIRS positive. Statistically significant differences were obtained between healthy and SIRS positive horses, while no differences were observed between healthy and SIRS negative horses at any sampling time. The best cutoff value of PCC to discriminate between SIRS positive, SIRS negative, and healthy horses, the sensitivity and specificity of cutoff point, the area under receiver operating characteristic curve, the 95% confidence intervals, and the likelihood ratio were reported. We found higher PCC values in sick SIRS-positive horses vs. healthy ones with a decrement over time, while no differences at admission, nor during the observational period, were obtained in sick but SIRS-negative horses. The value of 0.049 nmol/ml/mg is reported as a potential cutoff for the diagnosis of SIRS positivity vs. healthy horses with a sensibility of 74.5% and a specificity of 72.2%. In conclusion, PCC seems to be a sensitive and specific marker for SIRS in horses.

Loss of Reduction after Cephalomedullary Nail Fixation of Intertrochanteric Femoral Fracture: A Brief Report

Objective

At present, cephalomedullary nail is the most frequently used implant in the management of intertrochanteric fractures around the world. The implant design and fixation techniques of the cephalomedullary nail have been continuously improved to ensure uncomplicated bone union during the past decade. However, a degree of reduction loss during bone healing is still not rare in clinical work. Many attributed this complication to misoperation during the surgery and hold that a series of techniques and tips could help to avoid the loss of reduction. However, until now there has been no research to explore whether the reduction loss after the operation can be fully prevented in the best cases. The purposes of the study are as follows: (i) to evaluate the efficiency of the current established CMN techniques; (ii) to quantify the loss of reduction under an appropriately implanted CMN to anatomically realigned intertrochanteric fractures; and (iii) to explore the possible underlying causes for the inevitable loss of reduction.

Methods

In the retrospective study, 163 consecutive cases with the intertrochanteric fractures fixed with standard cephalomedullary nail technique were reviewed. The anatomical reduction and optimal positioning of the nail were confirmed by postoperative imaging. The fracture types ranged from 31‐A1.1–2.3 according to the OTA/AO fracture classification. One hundred and fifteen cases with stable fracture types (31A1.1–2.1) were allocated to Group A, and 48 cases with unstable 31A2.2–2.3 fracture types were allocated to Group B. The radiological measurements included femoral neck shortening, loss of the neck‐shaft angle, cutout, and cut‐through of the blade. The outcomes between postoperative and 1 year after the operation were evaluated and compared.

Results

The patients consisted of 66 males and 97 females with an average age of 69.4 (range: 46–78, SD: 14.6) years. At the 1‐year follow‐up, no fixation failure or nonunion was observed in each group. The mean femoral neck shortening and loss of the neck‐shaft angle were 4.47 mm (range: 0.43–17.68, SD: 3.71) and 5.4° (range: 0.51–19.10, SD: 3.58) separately. The mean cutout and cut‐through were 1.84 mm (range: 0.24–11.30, SD: 2.33) and 1.25 mm (range: 0.51–10.29, SD: 1.74). The average femoral neck shortening and loss of the neck‐shaft angle were higher in Group B than Group A. Among the 23 cases with the femoral neck shortening more than 10 mm, 19 cases (16.5%) were from Group A and four cases (8.3%) were from Group B. There were nine (7.8%) cases with the loss of the neck‐shaft angle more than 10° in Group A and six (12.5%) cases in Group B.

Conclusions

Current established CMN techniques are efficient in treating intertrochanteric femoral fracture. However, even with currently consensual techniques of cephalomedullary nail, the process of fracture healing still risks the loss of reduction, although the migration of the blade could be minimized. This situation may associate with the intrinsic design of the CMN and further improvement is still needed.

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

Purpose

The study aimed to examine the changing incidence of geriatric trauma and evaluate the predictive ability of different scoring tools for in-hospital mortality in geriatric trauma patients.

Methods

Annual reports released by the National Trauma Database (NTDB) in the USA from 2005 to 2015 and the Trauma Register DGU® in Germany from 1994 to 2012 were analyzed to examine the changing incidence of geriatric trauma. Secondary analysis of a single-center cohort study conducted among 311 severely injured geriatric trauma patients in a level I trauma center in Switzerland was completed. According to the in-hospital survival status, patients were divided into the survival and non-survival group. The differences of the ISS (injury severity score), NISS (new injury severity score), TRISS (Trauma and Injury Severity Score), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SPAS II (simplified acute physiology score II) between two groups were evaluated. Then, the areas under the receiver-operating characteristic curve (AUC-ROC) of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients were calculated.

Results

The analysis of the NTDB showed that the increase in the number of geriatric trauma ranged from 18 to 30% between 2005 and 2015. The analysis of the DGU® showed that the mean age of trauma patients rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥ 60 years rose from 16.5 to 37.5%. The findings from the secondary analysis showed that 164 (52.73%) patients died in the hospital. The ISS, NISS, APACHE II, and SAPS II in the death group were significantly higher than those in the survival group, and the TRISS in the death group was significantly lower than those in the survival group. The AUCs of the ISS, NISS, TRISS, APACHE II, and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients were 0.807, 0.850, 0.828, 0.715, and 0.725, respectively.

Conclusion

The total number of geriatric trauma is increasing as the population ages. The accuracy of ISS, NISS and TRISS was higher than the APACHE II and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients.

Effect of age at time of injury on long-term changes in intrinsic functional connectivity in traumatic brain injury

BACKGROUND

Alterations in resting-state functional connectivity (rsFC) occur in the acute and chronic phases following traumatic brain injury (TBI); however, few studies have assessed long-term (>1 year) changes in rsFC.

METHODS

Resting-state functional magnetic resonance imaging (rsfMRI) scans were obtained from the Federal Interagency Traumatic Brain Injury Research Informatics Systems. Patients with primarily mild TBI (n = 39) completed rsfMRI scans at the sub-acute (~10 days) and long-term (~18 months) phases. We examined changes in voxel-based rsFC from anterior medial prefrontal cortex (aMPFC) and posterior cingulate cortex (PCC) seeds in the default mode network (DMN) between both phases. The effect of age at the time of injury on long-term rsFC was also examined.

RESULTS

Increased rsFC from the aMPFC and the PCC to frontal and temporal regions was shown at ~18-months post-injury. Widespread increases in rsFC from the aMPFC and between the PCC and frontal regions were shown for younger patients at time of injury, but limited increases of rsFC were noted at ~18 months in older patients.

CONCLUSION

Long-term increases in rsFC were found following TBI, but age at the time of injury was associated with distinct rsFC profiles suggesting that younger patients show greater increases in rsFC over time.

Storage of an avulsed tooth prior to replantation: A systematic review and meta-analysis

BACKGROUND/AIM

It is crucial to store an avulsed tooth appropriately to preserve the viability of the periodontal ligament cells prior to replantation. The aim of this systematic review was to identify the best available evidence for the effectiveness of any technique available to laypeople for storing an avulsed tooth compared with storage in milk or saliva.

METHODS

The following databases were searched (September 2019): Cochrane Library, MEDLINE, and Embase. Two reviewers independently considered trial eligibility, then extracted and analyzed data, and assessed the risk of bias. The certainty of the body of evidence was appraised according to the GRADE methodology.

RESULTS

Out of 4118 references, 33 studies were included and reported 23 comparisons of which 10 were synthesized in a meta-analysis. The limited evidence available favors storing an avulsed tooth in Hank's balanced salt solution (pooled SMD 2.47, 95% CI [1.59;3.34], P < .00001), propolis solution (pooled SMD 1.73, 95% CI [1.12;2.33], P < .00001), oral rehydration salts (pooled SMD 4.16, 95% CI [2.10;6.23], P < .0001), rice water, and cling film compared with storage in milk. The cell viability rate was significantly lower in teeth stored in saline solutions (pooled SMD -4.35, 95% CI [-7.55;-1.14], P = .008), tap water, buttermilk, castor oil, GC Tooth Mousse, and turmeric extract than those stored in milk. There is insufficient evidence to recommend for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. The certainty of evidence was considered low to very low due to limitations in study design, indirect study populations and outcome measures, and imprecision.

CONCLUSION

Although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, the following media have also demonstrated efficacy at preserving the cell viability: Hank's balanced salt solution, propolis, oral rehydration salts, rice water, and cling film.

Split Thickness Skin Graft of the Foot and Ankle Bolstered With Negative Pressure Wound Therapy in a Diabetic Population: The Results of a Retrospective Review and Review of the Literature

Split thickness skin graft (STSG) is a versatile procedure performed for the treatment of wounds resulting from varying pathology. This remains very useful because of its ability for quick healing and low complication rate. The surface of the foot and ankle is an area frequently affected by severe skin and soft tissue structure infections (SSTIs) whose treatment results in wounds. These infections and resultant surgical wounds are commonly seen patients with diabetes. The objective of the present study was to retrospectively evaluate initial healing and immediate post-operative outcomes following STSG application in a diabetic population when negative pressure wound therapy (NPWT) was used as a bolster. Ten patients were identified, including 11 surgical wounds, who underwent STSG bolstered with NPWT from January 2016 to October 2018. Mean follow-up was 13 months (range 1-33 months) with an average time to heal of 17 days (range 14-30 days) for 11 surgical wounds averaging 57 cm2 (range 6.3 - 91 cm2). Consistent improved outcomes have been demonstrated when compared to alternative bolstering techniques available in the literature making a STSG bolstered with NPWT a powerful tool in the reconstruction of diabetic foot wounds resulting from the treatment of infection.Levels of Evidence: Level IV.

Clinical value of bedside abdominal sonography performed by certified sonographer in emergency evaluation of blunt abdominal trauma

PURPOSE

To investigate the accuracy and efficiency of bedside ultrasonography application performed by certified sonographer in emergency patients with blunt abdominal trauma.

METHODS

The study was carried out from 2017 to 2019. Findings in operations or on computed tomography (CT) were used as references to evaluate the accuracy of bedside abdominal ultrasonography. The time needed for bedside abdominal ultrasonography or CT examination was collected separately to evaluate the efficiency of bedside abdominal ultrasonography application.

RESULTS

Bedside abdominal ultrasonography was performed in 106 patients with blunt abdominal trauma, of which 71 critical patients received surgery. The overall diagnostic accordance rate was 88.68%. The diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation, retroperitoneal hematoma and multiple abdominal organ injury were 100%, 94.73%, 94.12%, 20.00%, 100% and 81.48%, respectively. Among the 71 critical patients, the diagnostic accordance rate was 94.37%, in which the diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation and multiple abdominal organ injury were 100%, 100%, 100%, 20.00% and 100%. The mean time for imaging examination of bedside abdominal ultrasonography was longer than that for CT scan (4.45 ± 1.63 vs. 2.38 ± 1.19) min; however, the mean waiting time before examination (7.37 ± 2.01 vs. 16.42 ± 6.37) min, the time to make a diagnostic report (6.42 ± 3.35 vs. 36.26 ± 13.33) min, and the overall time (17.24 ± 2.33 vs. 55.06 ± 6.96) min were shorter for bedside abdominal ultrasonography than for CT scan.

CONCLUSION

Bedside ultrasonography application provides both efficiency and reliability for the assessment of blunt abdominal trauma. Especially for patients with free peritoneal effusion and critical patients, bedside ultrasonography has been proved obvious advantageous. However, for negative bedside ultrasonography patients with blunt abdominal trauma, we recommend further abdominal CT scan or serial ultrasonography scans subsequently.

Neuroimmune Mechanisms and Sex/Gender-Dependent Effects in the Pathophysiology of Mental Disorders

Innate and adaptive immune mechanisms have emerged as critical regulators of CNS homeostasis and mental health. A plethora of immunologic factors have been reported to interact with emotion- and behavior-related neuronal circuits, modulating susceptibility and resilience to mental disorders. However, it remains unclear whether immune dysregulation is a cardinal causal factor or an outcome of the pathologies associated with mental disorders. Emerging variations in immune regulatory pathways based on sex differences provide an additional framework for discussion in these psychiatric disorders. In this review, we present the current literature pertaining to the effects that disrupted immune pathways have in mental disorder pathophysiology, including immune dysregulation in CNS and periphery, microglial activation, and disturbances of the blood-brain barrier. In addition, we present the suggested origins of such immune dysregulation and discuss the gender and sex influence of the neuroimmune substrates that contribute to mental disorders. The findings challenge the conventional view of these disorders and open the window to a diverse spectrum of innovative therapeutic targets that focus on the immune-specific pathophenotypes in neuronal circuits and behavior. SIGNIFICANCE STATEMENT: The involvement of gender-dependent inflammatory mechanisms on the development of mental pathologies is gaining momentum. This review addresses these novel factors and presents the accumulating evidence introducing microglia and proinflammatory elements as critical components and potential targets for the treatment of mental disorders.

Association of Thyroid Function with Posttraumatic Stress Disorder: a Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis describing the association of thyroid function with posttraumatic stress disorder (PTSD) in adults.

METHODS

The authors conducted a comprehensive search from databases' inception to July 20, 2018. The meta-analysis included studies that reported mean values and standard deviation (SD) of thyroid hormone levels (thyroid-stimulating hormone [TSH], free thyroxine [FT4], free triiodothyronine [FT3], total T4 [TT4], and total T3 [TT3]) in patients with PTSD compared with controls. Five reviewers worked independently, in duplicate, to determine study inclusion, extract data, and assess risk of bias. The mean value and SD of the thyroid function tests were used to calculate the mean difference for each variable. Random-effects models for meta-analyses were applied.

RESULTS

The meta-analysis included 10 observational studies at low-to-moderate risk of bias. Studies included 674 adults (373 PTSD, 301 controls). The meta-analytic estimates showed higher levels of FT3 (+0.28 pg/mL; P = .001) and TT3 (+18.90 ng/dL; P = .005) in patients with PTSD compared to controls. There were no differences in TSH, FT4, or TT4 levels between groups. In the subgroup analysis, patients with combat-related PTSD still had higher FT3 (+0.36 pg/mL; P = .0004) and higher TT3 (+31.62 ng/dL; P<.00001) compared with controls. Conversely, patients with non-combat-related PTSD did not have differences in FT3 or TT3 levels compared with controls.

CONCLUSION

There is scarce evidence regarding the association of thyroid disorders with PTSD. These findings add to the growing literature suggesting that thyroid function changes may be associated with PTSD.

Narcolepsy type 2: A rare, yet existing entity

Because of unspecific diagnostic criteria, there is much controversy around narcolepsy type 2, its existence and its frequency. With this retrospective and purely descriptive study, we aimed to compare the frequency of narcolepsy type 2 compared to the well-described narcolepsy type 1, in a large (n = 3,782) retrospective sample from a single tertiary sleep centre. After 2 weeks washout of sleep-wake active medication, all patients with excessive daytime sleepiness (n = 1,392) underwent 2 weeks actigraphy, polysomnography and multiple sleep latency test, and all diagnoses were made along current diagnostic criteria. Narcolepsy type 1 was diagnosed in 91 patients, and 191 patients without cataplexy had multiple sleep latency test (MSLT) results indicating narcolepsy. After exclusion of shift work syndrome (n = 19), suspected insufficient sleep syndrome (n = 128), delayed sleep phase syndrome (n = 4) and obstructive sleep apnea (n = 34), six patients were diagnosed with narcolepsy type 2, of whom two patients later developed narcolepsy type 1. Altogether, our observations suggest that narcolepsy type 2 exists, but its frequency may be much lower compared to narcolepsy type 1. In addition, they emphasize the importance of scrupulously excluding other potential causes of sleepiness, if possible, with 2-week actigraphy and polysomnography.

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

Objective

To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST.

Methods

This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST.

Results

FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038).

Conclusion

Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available.

Neurodegeneration exposes firing rate dependent effects on oscillation dynamics in computational neural networks

Traumatic brain injury (TBI) can lead to neurodegeneration in the injured circuitry, either through primary structural damage to the neuron or secondary effects that disrupt key cellular processes. Moreover, traumatic injuries can preferentially impact subpopulations of neurons, but the functional network effects of these targeted degeneration profiles remain unclear. Although isolating the consequences of complex injury dynamics and long-term recovery of the circuit can be difficult to control experimentally, computational networks can be a powerful tool to analyze the consequences of injury. Here, we use the Izhikevich spiking neuron model to create networks representative of cortical tissue. After an initial settling period with spike-timing-dependent plasticity (STDP), networks developed rhythmic oscillations similar to those seen in vivo. As neurons were sequentially removed from the network, population activity rate and oscillation dynamics were significantly reduced. In a successive period of network restructuring with STDP, network activity levels returned to baseline for some injury levels and oscillation dynamics significantly improved. We next explored the role that specific neurons have in the creation and termination of oscillation dynamics. We determined that oscillations initiate from activation of low firing rate neurons with limited structural inputs. To terminate oscillations, high activity excitatory neurons with strong input connectivity activate downstream inhibitory circuitry. Finally, we confirm the excitatory neuron population role through targeted neurodegeneration. These results suggest targeted neurodegeneration can play a key role in the oscillation dynamics after injury.

Does Time From Injury to Surgery Affect Outcomes After Surgical Repair of Partial and Complete Proximal Hamstring Ruptures?

Background

No previous study has compared the outcomes of repair for partial and complete proximal hamstring ruptures at various intervals after the injury.

Purpose

The primary aim was to determine whether time from injury to surgery affected outcomes after primary repair of partial and complete proximal hamstring ruptures. The secondary aim was to assess patients' experiences from initial evaluation to finding a treating surgeon.

Study Design

Cohort study; Level of evidence, 3.

Methods

Records from 2007 to 2016 from a single surgeon's practice were reviewed. A total of 124 proximal hamstring repair procedures in 121 patients were identified. There were 92 patients who completed questionnaires: a custom survey, the standard Lower Extremity Functional Scale (LEFS), a custom LEFS, the standard Marx activity scale, a custom Marx activity scale, and the University of California Los Angeles (UCLA) activity score. Results were analyzed for partial and complete repair procedures performed at ≤3 weeks, ≤6 weeks, and >6 weeks after the injury.

Results

The mean follow-up was 43 months (median, 38 months). Of 93 repair procedures reviewed, 51% (9/28 partial; 38/65 complete), 79% (16/28 partial; 57/65 complete), and 22% (12/28 partial; 8/65 complete) were performed at ≤3 weeks, ≤6 weeks, and >6 weeks, respectively. At those various intervals, no statistical difference was found in standard LEFS, custom LEFS, standard Marx, custom Marx, or UCLA scores. Female sex, older age, and body mass index >30 kg/m² were negative predictors of outcome measures. When repaired >6 weeks after the injury, a greater percentage of patients reported weakness of the operative leg compared with the contralateral side (partial tears: 6.3% vs 25%, respectively; complete tears: 24.6% vs 50%, respectively) in addition to greater sitting intolerance (partial tears: 0% vs 25%, respectively; complete tears: 7.1% vs 12.5%, respectively). Patients repaired >6 weeks after the injury visited, on average, 2.6 practitioners before an evaluation by the treating surgeon compared with 1.6 treated surgically at ≤6 weeks (P = .008).

Conclusion

Patients with proximal hamstring repair performed in the acute and chronic settings can expect successful outcomes but may experience more subjective weakness and difficulty with prolonged sitting when the repair is performed >6 weeks after the injury. Patients faced challenges in receiving the correct diagnosis and referral to an appropriate treating surgeon, emphasizing the need for an increased awareness of the injury.

Prospective study of the association between sport-related concussion and brain morphometry (3T-MRI) in collegiate athletes: study from the NCAA-DoD CARE Consortium

OBJECTIVES

To determine the acute and early long-term associations of sport-related concussion (SRC) and subcortical and cortical structures in collegiate contact sport athletes.

METHODS

Athletes with a recent SRC (n=99) and matched contact (n=91) and non-contact sport controls (n=95) completed up to four neuroimaging sessions from 24 to 48 hours to 6 months postinjury. Subcortical volumes (amygdala, hippocampus, thalamus and dorsal striatum) and vertex-wise measurements of cortical thickness/volume were computed using FreeSurfer. Linear mixed-effects models examined the acute and longitudinal associations between concussion and structural metrics, controlling for intracranial volume (or mean thickness) and demographic variables (including prior concussions and sport exposure).

RESULTS

There were significant group-dependent changes in amygdala volumes across visits (p=0.041); this effect was driven by a trend for increased amygdala volume at 6 months relative to subacute visits in contact controls, with no differences in athletes with SRC. No differences were observed in any cortical metric (ie, thickness or volume) for primary or secondary analyses.

CONCLUSION

A single SRC had minimal associations with grey matter structure across a 6-month time frame.

The role of IL-6 and other mediators in the cytokine storm associated with SARS-CoV-2 infection

The coronavirus disease 2019 pandemic caused by severe acute respiratory syndrome coronavirus 2 presents with a spectrum of clinical manifestations from asymptomatic or mild, self-limited constitutional symptoms to a hyperinflammatory state ("cytokine storm") followed by acute respiratory distress syndrome and death. The objective of this study was to provide an evidence-based review of the associated pathways and potential treatment of the hyperinflammatory state associated with severe acute respiratory syndrome coronavirus 2 infection. Dysregulated immune responses have been reported to occur in a smaller subset of those infected with severe acute respiratory syndrome coronavirus 2, leading to clinical deterioration 7 to 10 days after initial presentation. A hyperinflammatory state referred to as cytokine storm in its severest form has been marked by elevation of IL-6, IL-10, TNF-α, and other cytokines and severe CD4+ and CD8+ T-cell lymphopenia and coagulopathy. Recognition of at-risk patients could permit early institution of aggressive intensive care and antiviral and immune treatment to reduce the complications related to this proinflammatory state. Several reports and ongoing clinical trials provide hope that available immunomodulatory therapies could have therapeutic potential in these severe cases. This review highlights our current state of knowledge of immune mechanisms and targeted immunomodulatory treatment options for the current coronavirus disease 2019 pandemic.

Influence of Obesity on the Organization of the Extracellular Matrix and Satellite Cell Functions After Combined Muscle and Thorax Trauma in C57BL/6J Mice

Obesity has been described as a major factor of health risk in modern society. Next to intricately linked comorbidities like coronary artery disease or diabetes, an influence of obesity on regeneration after muscle injury has been described previously. However, the influence of obesity on tissue regeneration in a combined trauma, merging the more systemic influence of a blunt lung trauma and the local blunt muscle trauma, has not been investigated yet. Therefore, the aim of this study was to investigate the influence of obesity on regeneration in a mouse model that combined both muscle and thorax trauma. Using gene expression analysis, a focus was put on the structure as well as the organization of the extracellular matrix and on functional satellite cell physiology. An increased amount of debris in the lung of obese mice compared to normal weight mice up to 192 h after combined trauma based on visual assessment can be reported which is accompanied by a decreased response of Mmp2 in obese mice. Additionally, a delayed and elongated response of inhibitor genes like Timp1 has been revealed in obese mice. This elongated response to the trauma in obese mice can also be seen in plasma based on increased levels of pro-inflammatory chemo- and cytokines (IL-6, MCP-1, and IL 23) 192 h post trauma. In addition to changes in the lung, morphological analysis of the injured extensor iliotibialis anticus of the left hind leg in lean and diet-induced obese mice revealed deposition of fat in the regenerating muscle in obese animals hindering the structure of a compact muscle. Additionally, decreased activation of satellite cells and changes in organization and build-up of the ECM could be detected, finally leading to a decreased stability of the regenerated muscle in obese mice. Both factors contribute to an attenuated response to the trauma by obese mice which is reflected by a statistically significant decrease in muscle force of obese mice compared to lean mice 192 h post trauma induction.

Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients

The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36–68), the overall Injury Severity Score (ISS) was 24 points (IQR 17–29), and a median BMI of 25.1 points (IQR 23–28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued.

The Critical Roles and Mechanisms of Immune Cell Death in Sepsis

Sepsis was first described by the ancient Greek physicians over 2000 years ago. The pathophysiology of the disease, however, is still not fully understood and hence the mortality rate is still unacceptably high due to lack of specific therapies. In the last decade, great progress has been made by shifting the focus of research from systemic inflammatory response syndrome (SIRS) to multiple organ dysfunction syndrome (MODS). Sepsis has been re-defined as infection-induced MODS in 2016. How infection leads to MODS is not clear, but what mediates MODS becomes the major topic in understanding the molecular mechanisms and developing specific therapies. Recently, the mechanism of infection-induced extensive immune cell death which releases a large quantity of damage-associated molecular patterns (DAMPs) and their roles in the development of MODS as well as immunosuppression during sepsis have attracted much attention. Growing evidence supports the hypothesis that DAMPs, including high-mobility group box 1 protein (HMGB1), cell-free DNA (cfDNA) and histones as well as neutrophil extracellular traps (NETs), may directly or indirectly contribute significantly to the development of MODS. Here, we provide an overview of the mechanisms and consequences of infection-induced extensive immune cell death during the development of sepsis. We also propose a pivotal pathway from a local infection to eventual sepsis and a potential combined therapeutic strategy for targeting sepsis.

Functional connectivity of the anterior cingulate cortex in Veterans with mild traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is one of the most prevalent injuries in the military with mild traumatic brain injury (mTBI) accounting for approximately 70-80 % of all TBI. TBI has been associated with diffuse and focal brain changes to structures and networks underlying cognitive-emotional processing. Although the anterior cingulate cortex (ACC) plays a critical role in emotion regulation and executive function and is susceptible to mTBI, studies focusing on ACC resting state functional connectivity (rs-fc) in Veterans are limited.

METHODS

Veterans with mTBI (n = 49) and with no history of TBI (n = 25), ages 20-54 completed clinical assessments and an 8-minute resting state functional magnetic resonance imaging (rs-fMRI) on a 3 T Siemens scanner. Imaging results were analyzed with left and right ACC as seed regions using SPM8. Regression analyses were performed with time since injury.

RESULTS

Seed-based analysis showed increased connectivity of the left and right ACC with brain regions including middle and posterior cingulate regions, preceneus, and occipital regions in the mTBI compared to the non-TBI group.

CONCLUSIONS

The rs-fMRI results indicate hyperconnectivity in Veterans with mTBI. These results are consistent with previous studies of recently concussed athletes showing ACC hyperconnectivity. Enhanced top-down control of attention networks necessary to compensate for the microstructural damage following mTBI may explain ACC hyperconnectivity post-mTBI.

Outcomes with Two Tapered Wedge Femoral Stems in Total Hip Arthroplasty Using an Anterior Approach

Background

The majority of hip arthroplasties in the United States utilize cementless acetabular and femoral components. Despite their similarities, stem geometry can still differ. The purpose of this study is to compare the clinical results of two wedge-type stem designs.

Methods

A retrospective study of patients who underwent primary THA utilizing a direct anterior approach between January 2016 and January 2017. Two cohorts were established based on femoral stem design implanted. Descriptive patient characteristics and surgical and clinical data was extracted which included surgical time, length of stay (LOS), presence of pain (categorized as groin, hip, or thigh pain) at the latest follow-up, and revisions. Immediate postoperative radiographs were compared with the latest follow-up radiographs to assess limb length discrepancies, stem alignment, and stem subsidence.

Results

A total of 544 patients were included. 297 patients received the Group A stem (morphometric) and 247 patients received the Group B stem (flat-tapered). A significantly higher proportion of Group B stems subsided ≥3 mm and were in varus alignment than the Group A design. Additionally, a significantly greater number of patients who received the Group B stem reported postoperative hip and thigh pain. The logistic regression found that the Group B stem was 2.32 times more likely to subside ≥3 mm than the Group A stem.

Conclusion

Our study suggests modestly improved radiographic and clinical outcomes and fewer instances of thigh pain, subsidence, and varus alignment in the patients who received the Group Ahip stem. Further studies are warranted to assess long-term significance.

The Septic Neutrophil-Friend or Foe

ABSTRACT

Neutrophils play a critical role in the eradication of pathogenic organisms, particularly bacteria. However, in the septic patient the prolonged activation and accumulation of neutrophils may augment tissue and organ injury. This review discusses the different activation states and chemotaxis of neutrophils in septic patients. Neutrophil killing of bacteria and the formation of neutrophil extracellular traps represent important components of the innate immune response and they become dysregulated during sepsis, possibly through changes in their metabolism. Delayed neutrophil apoptosis may contribute to organ injury, or allow better clearance of pathogens. Neutrophils provide a friendly immune response to clear infections, but excessive activation and recruitment has the potential to turn them into potent foes.

Association between peripheral blood levels of C-reactive protein and Autism Spectrum Disorder in children: A systematic review and meta-analysis

INTRODUCTION

In the past five years, a growing number of studies have tried to illustrate the association between the peripheral blood level of C-reactive protein (CRP) and Autism Spectrum Disorders (ASD). However, the results have been inconsistent. To assess whether abnormal CRP in peripheral blood was associated with ASD, we conducted a systematic review and meta-analysis.

METHODS

A systematic literature search was performed using the Embase, PubMed, Web of Knowledge, PsycINFO, and Cochrane databases through August 27, 2019. Reference lists were also checked by hand-searching. Clinical studies exploring CRP concentration in the peripheral blood of autistic children and healthy controls were included in our meta-analysis. Overlapping samples were excluded. We pooled obtained data using a fixed- or random-effect model based on a heterogeneity test with Comprehensive Meta-Analysis software and STATA software. Standardized mean differences were converted to Hedges' g statistic in order to obtain the effect size adjusted for sample size. Subgroup analyses, sensitivity analyses, meta-regression, and publication bias tests were also undertaken.

RESULTS

Nine studies with 592 ASD children and 604 healthy children were included in our meta-analysis. Significantly elevated CRP levels in peripheral blood were found in ASD children compared with healthy controls (Hedges' g = 0.527, 95% CI: 0.224-0.830, p = 0.001). Subgroup analyses based on sample types and ethnicity also showed similar results, except for the plasma subgroup. There was also a significant association between peripheral CRP concentration and ASD after removing the studies identified by Galbraith plots. The results of the sensitivity analysis revealed that no single study could reverse our results. Meta-regression analyses revealed that the gender of autistic children had a moderating effect on the outcome of the meta-analysis. In addition, no obvious publication bias was found in the meta-analysis.

CONCLUSIONS AND RELEVANCE

In our study, peripheral CRP levels were significantly elevated in autistic children compared with healthy children. These results may provide us some new insights about ASD.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging

AIM

(1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups.

METHODS

Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient.

RESULTS

Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05).

CONCLUSION

One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

Scapholunate Diastasis in Distal Radius Fractures: Fracture Pattern Analysis on CT Scans

Objectives  Our understanding of distal radius fractures with concomitant scapholunate (SL) diastasis primarily comes from plain radiographs and arthroscopy. The clinical implications of SL diastasis are not clear. The aim of this study is to describe fracture characteristics of distal radius fractures on computed tomography (CT) scans in patients with distal radius fractures and static SL diastasis. Methods  We queried our institutional databases to identify patients who were treated for a distal radius fracture, had a CT scan with a wrist-protocol, and static SL diastasis on their CT scan. Our final cohort consisted of 26 patients. We then collected data on their demographics, injury, treatment, evaluated injury patterns, and measured radiographic SL characteristics. Our study cohort consisted of 11 men (42%) and almost half of our cohort ( n  = 12; 46%) had a high-energy mechanism of injury. The majority of the patients ( n  = 20; 77%) had operative treatment for their distal radius fracture and two patients (7.7%) had operative treatment of their SL injury. Results  The mean SL distance was 3.5 ± 1.1 mm. Twenty patients (77%) had an intra-articular fracture. In these patients, we observed three patterns: (1) scaphoid facet impaction; (2) lunate facet impaction; and (3) no relative impaction. We observed other injury elements including rotation of the radial styloid relative to the lunate facet and partial carpal subluxations. Conclusion  Static SL dissociation in the setting of distal radius fractures may be an indication of a complex injury of the distal radius, which may not be directly apparent on plain radiography. If these radiographs do not demonstrate impaction of the lunate or scaphoid facet, a CT scan may be warranted to have a more detailed view of the articular surface. Level of Evidence  This is a Level III, diagnostic study.

Damage-associated molecular patterns in trauma

In 1994, the "danger model" argued that adaptive immune responses are driven rather by molecules released upon tissue damage than by the recognition of "strange" molecules. Thus, an alternative to the "self versus non-self recognition model" has been provided. The model, which suggests that the immune system discriminates dangerous from safe molecules, has established the basis for the future designation of damage-associated molecular patterns (DAMPs), a term that was coined by Walter G. Land, Seong, and Matzinger. The pathological importance of DAMPs is barely somewhere else evident as in the posttraumatic or post-surgical inflammation and regeneration. Since DAMPs have been identified to trigger specific immune responses and inflammation, which is not necessarily detrimental but also regenerative, it still remains difficult to describe their "friend or foe" role in the posttraumatic immunogenicity and healing process. DAMPs can be used as biomarkers to indicate and/or to monitor a disease or injury severity, but they also may serve as clinically applicable parameters for optimized indication of the timing for, i.e., secondary surgeries. While experimental studies allow the detection of these biomarkers on different levels including cellular, tissue, and circulatory milieu, this is not always easily transferable to the human situation. Thus, in this review, we focus on the recent literature dealing with the pathophysiological importance of DAMPs after traumatic injury. Since dysregulated inflammation in traumatized patients always implies disturbed resolution of inflammation, so-called model of suppressing/inhibiting inducible DAMPs (SAMPs) will be very briefly introduced. Thus, an update on this topic in the field of trauma will be provided.

Proteolysis targeting chimeras (PROTACs) are emerging therapeutics for hematologic malignancies

Proteolysis targeting chimeras (PROTACs) are heterobifunctional small molecules that utilize the ubiquitin proteasome system (UPS) to degrade proteins of interest (POI). PROTACs are potentially superior to conventional small molecule inhibitors (SMIs) because of their unique mechanism of action (MOA, i.e., degrading POI in a sub-stoichiometric manner), ability to target "undruggable" and mutant proteins, and improved target selectivity. Therefore, PROTACs have become an emerging technology for the development of novel targeted anticancer therapeutics. In fact, some of these reported PROTACs exhibit unprecedented efficacy and specificity in degrading various oncogenic proteins and have advanced to various stages of preclinical and clinical development for the treatment of cancer and hematologic malignancy. In this review, we systematically summarize the known PROTACs that have the potential to be used to treat various hematologic malignancies and discuss strategies to improve the safety of PROTACs for clinical application. Particularly, we propose to use the latest human pan-tissue single-cell RNA sequencing data to identify hematopoietic cell type-specific/selective E3 ligases to generate tumor-specific/selective PROTACs. These PROTACs have the potential to become safer therapeutics for hematologic malignancies because they can overcome some of the on-target toxicities of SMIs and PROTACs.

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality

BACKGROUND

The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA.

METHODS

Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.

RESULTS

Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]).

CONCLUSIONS

REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.

Is the Additional Effort for an Intraoperative CT Scan Justified for Distal Radius Fracture Fixations? A Comparative Clinical Feasibility Study

INTRODUCTION

It is currently unclear whether the additional effort to perform an intraoperative computed tomography (CT) scan is justified for articular distal radius fractures (DRFs). The purpose of this study was to assess radiological, functional, and clinical outcomes after surgical treatment of distal radius fractures when using conventional fluoroscopy vs. intraoperative CT scans.

METHODS

Inclusion criteria: Surgical treatment of DRF between 1 January 2011 and 31 December 2011, age 18 and above. Group distribution: intraoperative conventional fluoroscopy (Group Conv) or intraoperative CT scans (Group CT).

EXCLUSION CRITERIA

Use of different image intensifier devices or incomplete data. DRF classification according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Outcome variables included requirement of revision surgeries, duration of surgery, absorbed radiation dose, and requirement of additional CT scans during hospitalization.

RESULTS

A total of 187 patients were included (Group Conv n = 96 (51.3%), Group CT n = 91 (48.7%)). AO Classification: Type A fractures n = 40 (50%) in Group Conv vs. n = 16 (17.6%) in Group CT, p < 0.001; Type B: 10 (10.4%) vs. 11 (12.1%), not significant (n.s.); Type C: 38 (39.6%) vs. 64 (70.3%), p < 0.001. In Group Conv, four (4.2%) patients required revision surgeries within 6 months, but in Group CT no revision surgery was required. The CT scan led to an intraoperative screw exchange/reposition in 23 (25.3%) cases. The duration of the initial surgery (81.7 ± 46.4 min vs. 90.1 ± 43.6 min, n.s.) was comparable. The radiation dose was significantly higher in Group CT (6.9 ± 1.3 vs. 2.8 ± 7.8 mGy, p < 0.001). In Group Conv, 11 (11.5%) patients required additional CT scans during hospitalization.

CONCLUSION

The usage of intraoperative CT was associated with improved reduction and more adequate positioning of screws postoperatively with comparable durations of surgery. Despite increased efforts by utilizing the intraoperative CT scan, the decrease in reoperations may justify its use.

Volar Locked Plating Versus Closed Reduction and Casting for Acute, Displaced Distal Radial Fractures in the Elderly: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

It remains unclear whether volar locked plating (VLP) yields a better functional outcome than closed reduction and casting (CRC) for elderly patients with an acute, displaced distal radial fracture. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials comparing outcomes of VLP and CRC for elderly patients (age, ≥60 years).

METHODS

Multiple databases, including MEDLINE, were searched for randomized controlled trials evaluating outcomes following distal radial fracture treatment. Raw data were obtained for studies that included patients of all ages, and the elderly subgroup was included for analysis. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at ≥1 year of follow-up. Secondary outcomes included the 3-month DASH score, range of motion, final radiographic alignment, and complications. Effect sizes for the comparison of each outcome between groups were pooled across studies using random-effects models with the inverse variance weighting method. Changes in DASH score were compared with a minimal clinically important difference (MCID) estimate of 10 to assess clinical relevance.

RESULTS

Of 2,152 screened articles, 6 were included. Demographics were similar for the 274 VLP and 287 CRC patients. DASH scores were significantly better following VLP than CRC at the time of final follow-up (12 to 24 months postoperatively; score difference, -5.9; 95% confidence interval [CI], -8.7 to -3.1) and at 3 months (-8.9; 95% CI, -13.0 to -4.8). VLP yielded significantly better palmar tilt, radial inclination, and supination, with no differences in ulnar variance, flexion-extension, pronation, or total complication rates.

CONCLUSIONS

Functional outcome was significantly better following VLP than CRC 3 months into the treatment of acute, displaced distal radial fractures in an elderly population and up to 2 years after injury. However, the observed differences in the final DASH score did not exceed published estimates of the MCID, suggesting that clinical outcomes are similar for both treatment options.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Development of three-dimensional preoperative planning system for the osteosynthesis of distal humerus fractures

BACKGROUND

To reproduce anatomical reduction and appropriate implant placement/choices during osteosynthesis for elbow fractures, we developed a 3D preoperative planning system. To assess the utility of 3D digital preoperative planning for the osteosynthesis of distal humerus fractures, we evaluated the reproducibility of implant reduction shapes and placements in patients with distal humerus fractures.

METHODS

Twelve patients with distal humerus fractures who underwent osteosynthesis using 3D preoperative planning were evaluated. Reduction shapes were evaluated by the angle between the diaphysis axis and a line connecting the vertices of the medial epicondyle and the lateral epicondyle (epicondyle angle), and the angle between the diaphysis axis and the articular surface (joint angle) in the coronal plane, and the distance between the anterior diaphysis and the anterior articular surface in the sagittal plane (anterior distance) based on 3D images of the distal humerus. In addition, the implant positions were evaluated by the positions of the proximal and posterior edge of the plate, and the angle of the plate to the epicondyle line. The reproducibility was evaluated by intra-class correlation coefficients of the parameters between pre- and postoperative images.

RESULTS

The intra-class correlation coefficients were 0.545, 0.802, and 0.372 for the epicondyle angle, joint angle, and anterior distance, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 2.1 ± 2.1 degrees, 2.3 ± 1.8 degrees, and 2.8 ± 2.0 mm, for the epicondyle angle, joint angle, and anterior distance, respectively. The intra-class correlation coefficients were 0.983, 0.661, and 0.653 for the proximal and posterior plate positions, and the angle to the epicondyle, respectively. The differences in the measurements between the preoperative plan and postoperative reduction were 3.3 ± 2.1 mm, 2.7 ± 1.7 mm and 9.7 ± 9.8 degrees, for the plate positions of proximal and posterior edge, and the angle of the plate to the epicondyle line, respectively. There were significant correlations for the epicondyle angle, joint angle, and plate positions.

CONCLUSIONS

3D preoperative planning for osteosynthesis of distal humerus fracture was reproducible for the reduction shape of the coronal view and the plate positions. It may be helpful for acquiring practical images of osteosynthesis in distal humerus fractures.

LEVEL OF EVIDENCE

Level III, a case-control study.